What are the priority nursing actions for fluid volume overload?

This online nursing care plan below includes the following conditions: Fluid Volume Excess, Fluid Overload, Congestive Heart Failure, Pulmonary Edema, Ascites, Edema, and Fluid and Electrolyte Imbalance.

What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?

This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.

Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.

Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.

Nursing Care Plan for: Fluid Volume Excess, Fluid Overload, Congestive Heart Failure, Pulmonary Edema, Ascites, Edema, and Fluid and Electrolyte Imbalance.

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.

Scenario:

A 74 year old male presents to the ER with complaints of swelling in legs and feet, shortness of breath with any type of activity, non-radiating chest pain, increase cough, and the inability to sleep laying down at night. Pt states he has felt bad since Tuesday and today is Friday. He also states he has gained 7 pounds since he last weight on Tuesday. Pt currently weighs 210 lbs. Pt states he usually weighs around 200-203 lbs.  During history collection from pt, pt becomes short of breath and has to stop talking to catch his breath. Pt states that he takes Lasix 60mg PO BID but has not taken any since Monday because he wasn’t able to go to the pharmacy due to the snowstorm last week. Pt also takes Lisinopril 2.5 mg PO BID, Coreg 6.25mg PO Daily, Coumadin 5mg PO Daily (has a history of Atrial fibrillation), Potassium PO 20meq BID, and Multivitamin 1 Tab PO Daily. Vital Signs: BP 155/93, HR 95, O2 Sat 90% on 4L nasal cannula, Temp. 98.6. On assessment, 3+ pitting edema noted in lower extremities, bilateral crackles noted through out lung fields, hands and abdomen are swollen, and slight jugular distention noted. Lab and Diagnostic work shows: BNAT 1824, K+5.0, Creatinine 1.8, BUN 21, chest x-ray preliminary results show possible bilateral pleural effusions, and echo-cardiogram results show ejection fraction of 35%.

 

Nursing Diagnosis:

Fluid volume overload related to decreased cardiac output as evidence by ejection fraction of 35%, edema in lower extremities, jugular distention, bilateral crackles, weight gain, BNAT 1824, and pleural effusions noted in lungs bilaterally.

Subjective Data:

Complaints of shortness of breath on any type of activity, non-radiating chest pain, increase cough, and the inability to sleep laying down at night, gained 7 pounds since last weight on Tuesday, takes Lasix 60mg PO BID but has not taken any since Monday because he wasn’t able to go to the pharmacy due to the snowstorm last week.

Objective Data:

Lisinopril 2.5 mg PO BID, Coreg 6.25mg PO Daily, Coumadin 5mg PO Daily (has a history of Atrial fibrillation), Potassium PO 20meq BID, and Multivitamin 1 Tab PO Daily. Vital Signs: BP 155/93, HR 95, O2 Sat 90% on 4L nasal cannula, Temp. 98.6, 3+ pitting edema noted in lower extremites, bilateral crackles noted through out lung fields, hands and abdomen are swollen, and slight jugular distention noted. Lab and Diagnostic work shows: BNAT 1824, K+5.0, Creatinine 1.8, BUN 21, chest x-ray preliminary results show possible bilateral pleural effusions, and echo-cardiogram results show ejection fraction of 35%.

Nursing Outcomes:

-Pt’s O2 Saturation will be between 90-100% as evidence by nursing documentation during hospitalization.-Pt will weigh 200 lbs by discharge.

-Pt will have no evidence of edema in lower extremities within 48 hours of hospitalization.

Nursing Interventions:

-Pt will be titrated on Oxygen via nasal cannula to keep O2 Sat. between 92-100% per MD order.-Pt will be given Lasix 60mg IV BID per MD order and will be weighed daily.

– Pt will be placed on a 1500 ml fluid restricted diet per MD order and Intake and Output will be monitor and calculated after each shift.

Nursing InterventionsScientific RationaleObtain patient history to ascertain the probable cause of the fluid disturbance.This will help to guide interventions.Assess or instruct patient to monitor weight daily and consistently, with same scale and preferably at the same time of day.To facilitate accurate measurement and to follow trends.Monitor and document vital signs.Sinus tachycardia and increased blood pressure are seen in early stages. Elderly patients have reduced response to catecholamines; thus their response to fluid overload may be blunted, with less rise in heart rate.Auscultate for a third sound, and assess for bounding peripheral pulses.These are signs of fluid overloadAssess for crackles in lungs, changes in respiratory pattern, shortness of breath, and orthopnea.For early recognition of pulmonary congestion.Monitor chest x-ray reports.As interstitial edema accumulates, the x-rays show cloudy white lung fields.Monitor input and output closely.To monitor fluid balance.Evaluate urine output in response to diuretic therapy.Focus is on monitoring the response to the diuretics, rather than the actual amount voided.Assess the need for an indwelling urinary catheter.Treatment focuses on diuresis of excess fluid.Institute/instruct patient regarding fluid restrictions as appropriate.To help reduce extracellular volume. For some patients, fluids may need to be restricted to 100 ml per day.Restrict sodium intake as prescribed.Sodium diets of 2 to 3 gm. are usually prescribed.Administer or instruct patient to take diuretics as prescribed.Diuretic therapy may include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem.Elevate edematous extremities.To increase venous return and, in turn, decrease edema.Reduce constriction of vessels (use appropriate garments, avoid crossing of legs or ankles).To prevent venous pooling.Instruct in need for antiembolic stockings or bandages as ordered.To help promote venous return and to minimize fluid accumulation in the extremities

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